Missouri is among the worst states when it comes to spending revenue brought in by a 20-year-old settlement with tobacco companies on programming to help people stop smoking or prevent them from smoking at all.

A 1998 legal settlement between 46 states and major tobacco companies required the companies to pay more than $246 billion over time as compensation for tobacco-related health care costs and provided funding for a public education campaign to prevent tobacco use among youth.

Twenty years after that settlement, the states will collect $27.3 billion in revenue this year but will spend only 2.4 percent of it — $655 million — on prevention and cessation programs, according to a report released last month by a collection of health advocacy groups.

Among states that spend at least a portion of the revenue that way, Missouri ranked last, spending $48,500 — or less than 0.1 percent of its $258.9 million in revenue — this year on such programs, according to the report. The U.S. Centers for Disease Control and Prevention recommends that Missouri spend at least $72.9 million on those programs each year.

‘Prioritization’

Legislatures aren’t obligated to spend their settlement money in any particular way. The settlement states that its purpose is to help decrease youth smoking and to promote public health, but it doesn’t contain any provisions requiring states to allocate those revenues to tobacco prevention, according to the Public Health Law Center.

As a result, most states use their settlement revenue to cover budget shortfalls or prioritize other programming, the law center said. Over the years, few states have allocated any more than a fraction of that money for tobacco prevention programs.

That has been the case in Missouri, where tobacco settlement funds for years have gone into the state’s general revenue fund. That means the money generally can be appropriated for almost anything, said Rep. Cody Smith, R-Carthage, chairman of the House Budget Committee.

When asked if lawmakers value tobacco prevention programs programs yet see a greater need elsewhere for spending their annual tobacco settlement dollars, Smith said yes. Choosing to allocate more of those dollars to prevention programs could draw money away from areas that also need funding commitments in the state’s $28 billion budget, such as K-12 education, higher education, transportation, Medicaid and public safety, he said.

“It’s a matter of prioritization,” he said.

Smith said there’s a “sense of awareness” in Jefferson City that prevention programs are effective, and he believes that sentiment is continually “trending upward.” Yet he didn’t know whether lawmakers this year will wish to spend more money on those programs, he said. His committee will likely begin meeting next month to develop the 2020 budget.

Officials with the Missouri Department of Health and Senior Services did not respond to an email from the Globe seeking comment about their tobacco prevention programs and how they’re funded.

Even though states aren’t obligated to spend their tobacco settlement on prevention programs, advocates argue that they should because tobacco use still kills more than 480,000 Americans and costs the nation about $170 billion in health care expenses each year.

“We know what it takes to prevent and reduce tobacco use: proven tobacco control policies that save lives,” said Harold P. Wimmer, president and CEO of the American Lung Association, one of the groups behind the study. “Despite the billions of dollars states continue to receive from the tobacco master settlement agreement, our state leaders are not funding these programs at levels recommended by the CDC. Fully funding tobacco control efforts is the smart choice for states; we know it works, and it saves both lives and health care costs.”

The CDC, which has recommended levels of funding for each state, says tobacco-prevention programs and policies are the “best buys” in public health for their ability to reduce health care costs of smoking-related illnesses.

Health risks

Smoking and tobacco use is a major national public health issue, said Philip Slocum, the medical director of the Lung Institute at Freeman Health System in Joplin.

“More people die from tobacco use than HIV, drugs, alcohol, firearms and motor-vehicle accidents combined,” he said, adding that tobacco-attributed deaths are largely preventable. “The biggest killer, we don’t even address.”

People who smoke are at an increased risk for multiple cancers and leukemia, as smoking affects nearly every organ in the body, he said. Smoking at an early age also can modify the receptors in a person’s brain, making it psychologically more reliant on continuing the habit for survival, he said. Approximately 11,000 deaths in Missouri are caused by smoking each year.

And it’s not just smokers who are at risk. Secondhand smoke is responsible for 1,000 infant deaths each year across the country as well as the development of ear infections and asthma in children, Slocum said. It also is a known cause of sudden infant death syndrome, he said.

Of particular concern to health groups in recent years is the rise of electronic cigarettes, which are increasingly attracting younger smokers. In Missouri, nearly 10 percent of high school students smoke, while another nearly 11 percent use e-cigarettes.

Across the country, e-cigarette use increased to 20.8 percent in high school students and to nearly 5 percent in middle school students in 2018 over the prior year, with more than 3.6 million students now using such devices. That increase is attributed, at least partly, to JUUL, which is described in the tobacco settlement report as a newer “high-tech e-cigarette that is small and easy to hide, comes in appealing flavors like mango and mint, and delivers a powerful dose of nicotine.”

Sales of JUUL grew more than seven-fold from 2016 to 2017 and held the greatest share of the U.S. e-cigarette market by December 2017, the CDC reported last fall. Use of JUUL by youth in schools, including in classrooms and bathrooms, has been widely reported, the CDC said.

“It is within our reach to win the fight against tobacco,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, one of the groups behind the report. “But we cannot let our guard down — not when smoking rates remain so high among certain populations and regions in our country, and not when e-cigarettes threaten to addict another generation of kids.”

Slocum said e-cigarettes might be “slightly less harmful” than cigarettes, but he still doesn’t recommended their use to his patients.

“You’re still taking unregulated material and putting it in your body,” he said.

Solutions

The report’s authors call for the implementation of several strategies they believe would continue to reduce tobacco use, including:

• Fully funded tobacco prevention and cessation programs.

• An increase in tobacco taxes. Missouri’s tax on cigarettes, at 17 cents per pack, is the lowest in the country.

• Laws raising the legal sale age for tobacco products to 21.

• Smoke-free laws, such as those in place in many public spaces including schools and government buildings.

• The prohibition of menthol cigarettes, flavored cigars and flavored e-cigarettes that have not been reviewed by the U.S. Food and Drug Administration.

Health-focused groups believe that a comprehensive approach to fighting tobacco use is what will make a difference.

“State officials must do their part through robust investments in proven tobacco prevention and cessation programs,” said Nancy Brown, CEO of the American Heart Association, one of the groups behind the report. “Sustained investments in tobacco prevention and cessation, combined with smoke-free workplace policies and tobacco tax increases, are necessary to break the cycle of addiction and save lives from tobacco use among all populations.”

The American Cancer Society’s Cancer Action Network, another group behind the report, advocates each year in Missouri for evidence-based tobacco prevention and cessation programs, said Emily Kalmer, the group’s government relations director in Missouri.

“We urge legislators to prioritize this funding because we know it saves lives,” she said in an email to the Globe. “Missouri also has the lowest tobacco tax in the country. We support increasing Missouri’s tobacco tax significantly so that we can reduce tobacco use.”

Kalmer said more than 5,000 people called Missouri’s Quitline in fiscal year 2018 — evidence, she said, that such programs work when funded. The Quitline, a free 24-hour hotline for people who want help in quitting tobacco use, provides counseling, information and referrals, and is available at 1-800-QUIT-NOW (1-800-784-8669).

“We know cessation and prevention programs work when funded and implemented as recommended by the CDC’s best practices for tobacco control,” Kalmer said.

Slocum, the Freeman physician, also recommended increasing taxes on cigarettes and funding prevention programs. Research shows that taxes higher than $2 per pack are linked to drops in the smoking rate, he said, while prevention programs work best to keep people from starting smoking at all.

Other states

Like Missouri, Kansas ranked in the bottom 10 states in terms of spending, giving $847,000 this year to tobacco prevention programs, according to the report. That amounts to about 3 percent of what the CDC recommends Kansas spend on such programs, which is $27.9 million, and about 0.4 percent of its annual tobacco revenue.

More than 17 percent of adults and 7 percent of high school students smoke, causing about 4,400 smoking-related deaths in Kansas each year, according to the report.

Oklahoma was ranked fourth, spending $21.3 million on tobacco prevention this year, which is slightly more than half of the CDC-recommended amount of $42.3 million, according to the report. That was an increase over the prior year, when the state spent $19 million on tobacco prevention programs, and it represented about 4 percent of its total annual tobacco revenue.

An estimated 20 percent of adult Oklahomans smoke, as do roughly 12.5 percent of high school students and 16 percent of high school students who use e-cigarettes. Approximately 7,500 deaths in Oklahoma are caused by smoking each year, according to the report.

Four states — Alaska, California, North Dakota and Oklahoma — spend more than half of their CDC recommendation on tobacco prevention programs. Three states — Tennessee, West Virginia and Connecticut — spent no public money this year on prevention programs, the report said.

About the report

The report, titled “Broken Promises to Our Children: A State-by-State Look at the 1998 Tobacco Settlement 20 Years Later,” was released by the Campaign for Tobacco-Free Kids, American Cancer Society’s Cancer Action Network, American Heart Association, American Lung Association, Robert Wood Johnson Foundation, Americans for Nonsmokers’ Rights, and Truth Initiative.